UCSF Medical Center – MyChart Proxy Authorization Form

Important Reminder: UCSF MyChart displays certain information from your medical records, but it does not display all health information in your medical records.

Parent/Legal Guardian of Child: This authorization form is used for minors under the age of 12, in which, Attorney for Health Care, Advance Health Care Directive, or legal guardianship papers may be requested. A renewal of this authorization may be requested as well. Expiration of pediatric proxy access automatically occurs on the patient's 12th birthday

AGREEMENT –

The UCSF Medical Center (UCSFMC) Terms and Conditions for UCSF MyChart, and the UCSF MyChart Proxy/Disclaimer for access to My Family’s Record UCSF MyChart section control this agreement between the child’s parent/legal guardian and UCSF Medical Center. Please refer to these documents when you signup online

YOUR RIGHTS

This Authorization to release health information is voluntary. You may revoke proxy access at any time to your family member’s UCSF MyChart account. For revocation, please contact your family member’s practice. The Revocation will take effect within 2 business days upon notification of your request except to the extent UCSF Medical Center or others have already relied on it.

REVOCATION/EXPIRATION OF AUTHORIZATION

Unless otherwise revoked, or ended by revocation, authorization for UCSF MyChart proxy access will expire automatically when the patient turns 18 years old. In order for revocation to be effective, it must be executed in writing.

If the parent/guardian is a UCSF patient

If the parent/guardian is NOT a UCSF patient

I attest that the above information is true and correct.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Parent/Legal Guardian Proxy – CHILD (0-11 years)

Dear Parent/Guardian,

Thank you for signing the UCSF MyChart Proxy Authorization form. This is the first step in allowing you to view some of your child’s health information online through our new patient portal we call UCSF MyChart.

UCSF MyChart patient portal is offered to you free of charge as an online resource for your child’s routine health care needs. UCSF MyChart can help you:

• Message your child’s provider
• Refill a current medication
• Check certain lab results and graph your child’s trends
• View some electronic health information
• Request an appointment or a referral on behalf of your child
• View past visit information for some services and upcoming appointments

Once you are linked to your child’s account, you will hear from us within a week – either by UCSF MyChart message or as a phone call. If you have any questions in the meantime, please call UCSF MyChart Customer Service at 415-514-6000 (M-F 8 am -5 pm) or email us at UCSFMyChart@ucsfmedctr.org.

This is what you will see when your child is linked to your UCSF MyChart account:

Once your child turns 12, they will be allowed to have their own UCSF MyChart account; as your child’s parent/guardian, you will be able to view some of their MyChart account. Proxies for teens 12-17 have access to adolescent test results, allergies, and immunizations; they can message their adolescent’s providers and request appointments on their adolescent’s behalf. Parents/guardians will not have access to information related to sensitive services, such as reproductive health (i.e. pregnancy testing, contraception, testing and treatment for sexually transmitted diseases), and certain mental health and substance use screening and treatments.

We look forward to continuing to provide you with your family’s health care needs.